907 KAR 20:055. Breast and cervical cancer eligibility for Medicaid.

 

      RELATES TO: 42 U.S.C. 1396a(aa)

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the requirements for the determination of Medicaid eligibility for low-income, uninsured women under the age of sixty-five (65) who have been identified by the Kentucky Women's Cancer Screening Program and are in need of treatment for breast or cervical cancer, including a precancerous condition and early stage cancer.

 

      Section 1. Definitions. (1) "Cabinet" means the Cabinet for Health and Family Services.

      (2) "CDC" means the federal Centers for Disease Control and Prevention.

      (3) "Creditable coverage" is defined in KRS 304.17A-005(7).

      (4) "Department" means the Department for Medicaid Services or its designated agent.

      (5) "Kentucky Women's Cancer Screening Program" means the program administered by the Department for Public Health which provides breast and cervical cancer screening and diagnostic services to low-income, uninsured or underinsured women using both state funds and monies from the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program, including Title XV funds.

      (6) "Qualified alien" means an alien who, at the time the alien applies for or receives Medicaid, meets the requirements established in 907 KAR 20:005, Section 2(2)(a)2 or 3.

 

      Section 2. Eligibility Criteria. A woman shall be eligible for Medicaid benefits if she:

      (1) Has not attained the age of sixty-five (65);

      (2) Is a United States citizen or qualified alien;

      (3) Is a resident of Kentucky;

      (4) Is not an individual described in any of the mandatory Medicaid categorically-needy eligibility groups;

      (5) Is not a resident of a public institution in accordance with 907 KAR 20:005, Section 6;

      (6) Has been:

      (a) Screened for breast or cervical cancer under the Kentucky Women's Cancer Screening Program; and

      (b) Found to need treatment for breast or cervical cancer, including a precancerous condition or early stage cancer;

      (7) Does not have creditable coverage unless the treatment of breast or cervical cancer is not:

      (a) A covered service; or

      (b) Covered due to:

      1. Exclusion as a preexisting condition;

      2. An HMO affiliation period; or

      3. Exhaustion of a lifetime limit on benefits; and

      (8) Has provided a Social Security number in accordance with 907 KAR 20:005, Section 11.

 

      Section 3. Limitation. A woman who is determined to require routine monitoring services for a precancerous breast or cervical condition shall not be considered to need treatment.

 

      Section 4. Eligibility Period. (1) Medicaid eligibility may be effective three (3) months prior to the month of application.

      (2) The length of Medicaid eligibility shall be as follows:

      (a) Four (4) months for the treatment of breast cancer;

      (b) Three (3) months for the treatment of cervical cancer; and

      (c) Two (2) months for the treatment of precancerous cervical or breast disorder.

      (3)(a) The department may grant an extension of eligibility if further treatment is necessary for breast or cervical cancer or a precancerous cervical or breast disorder.

      (b) To request an extension, the treating provider shall complete a MAP-813D, Breast and Cervical Cancer Treatment Program Request for Extension of Eligibility, and submit it to the department.

      (c) After receipt of the completed MAP-813D, the department shall notify the recipient of the eligibility extension period.

      (4) If the age of sixty-five (65) is attained during an eligible period, Medicaid eligibility shall be terminated at the end of the birth month.

 

      Section 5. Department for Public Health Responsibilities. A local health department shall:

      (1) In a joint effort with an applicant, complete a MAP-813B, BCCTP Eligibility Screening Form, to determine if the recipient is potentially eligible for Medicaid in another eligibility category;

      (2) Refer the applicant to the local Department for Community Based Services office if she is potentially eligible in another Medicaid group;

      (3) If the applicant is determined to meet the eligibility criteria established in Section 2 of this administrative regulation:

      (a) In conjunction with the applicant, complete a MAP-813, Breast and Cervical Cancer Treatment Program Application; and

      (b) Contact the department to obtain an authorization number; and

      (4) If an authorization number is received, provide the applicant's eligibility information to the department.

 

      Section 6. Recipient Responsibilities. The recipient shall be responsible for reporting to the department within ten (10) days a change in:

      (1) Breast or cervical cancer treatment status;

      (2) Creditable health insurance coverage;

      (3) Address; or

      (4) Another circumstance which may affect eligibility.

 

      Section 7. Appeal Rights. (1) An appeal regarding the Medicaid eligibility of an individual shall be conducted in accordance with 907 KAR 1:560.

      (2) If a woman is determined ineligible for the Kentucky Women's Cancer Screening Program, the appeal procedures shall be in accordance with 902 KAR 1:400.

 

      Section 8. Incorporation by Reference. (1) The following material is incorporated by reference:

      (a) "MAP-813B, BCCTP Eligibility Screening Form, September 9, 2002 edition," Department for Medicaid Services;

      (b) "MAP-813, Breast and Cervical Cancer Treatment Program Application, January 15, 2003 edition," Department for Medicaid Services; and

      (c) "MAP-813D, Breast and Cervical Cancer Treatment Program Request for Extension of Eligibility, January 15, 2003 edition," Department for Medicaid Services.

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. through 4:30 p.m. (30 Ky.R. 181; eff. 8-20-2003; Recodified from 907 KAR 1:805, 9-30-2013.)